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«FINAL REPORT 30 January 2013 U.S. Central Command Pre-Hospital Trauma Care Assessment Team Russ S. Kotwal, MD MPH COL, MC, USA Director of Trauma ...»

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208. The mission of the FDA is to ensure that drugs are safe and effective. The company bringing a drug to market must select the indication for the drug. Prospective, randomized trials are designed to demonstrate that the drug works for that indication. The company bears the expense for this testing. Once the drug is approved for one indication, physicians can use it for other indications. Drug companies therefore typically have little financial incentive to obtain additional labeled indications. This is especially true for military uses, since wars are hopefully the exception rather than the rule and do not provide a primary market for a medication. Offlabel use of medications is widespread and well-accepted in medical practice. The prospective, randomized trials needed for FDA approval are not possible on the battlefield. Civilian trauma trials cannot precisely duplicate battlefield trauma and medications are not labeled specifically for battlefield trauma. Therefore, most if not all uses of all medications on the battlefield are offlabel. The FDA and the military should acknowledge this as acceptable as long as such use is supported by the weight of the available clinical evidence. (CoTCCC Chairman)

209. Medics report that the Combat Ready Clamp (CRoC) is too bulky and heavy to carry on missions and takes too much time to assemble and apply. (BAF Role I – 1st Infantry Division, Shadow DUSTOFF; Role I – 75th Ranger Regiment) The optimal fielding of this device might be in a pre-assembled configuration and carried on tactical vehicles and evacuation aircraft.

(CoTCCC Chairman)

210. There should be a medical rapid fielding capability for potentially lifesaving new TCCC techniques and technology to include a transition team visit to deployed forces, initial supply, training, and testing of knowledge. (BAF Role I – 1st Infantry Division; 3rd Infantry Division;

Shadow DUSTOFF; CJSOTF; Role I – 75th Ranger Regiment; Tarin Kowt Role I – NSW;

Bastion Role I – USMC/USN)

211. 68W medics in the ground combat units interviewed are trained on and carrying the King LT and may have occasion to use them in Tactical Field Care (TFC).

212. The new Impact 731 ventilator needs to be expedited into theater. The older Impact 754 ventilator units are not performing well and frequently shut down while being used. (JTTS Deployed Director)

213. Medic participation in the Navy Medical Lessons Learned Center (NMLLC) TCCC equipment evaluation should be encouraged for all services and units. NMLLC should provide directed updates from this project to CENTCOM and deployed forces as appropriate.

–  –  –

215. Packaging for French freeze dried plasma (FDP) is not optimal for pre-hospital use.

USASOC units who carry French FDP modify packaging to accommodate as possible.

However, new packaging must be developed. (Role I – 75th Ranger Regiment)

216. For many units, initial issue of medical equipment occurs in theater after deployment, but should occur prior to pre-deployment training.

217. IOs are working. They are placed properly, but approximately 25% come out. The FAST-1 has a slower flow rate than the EZ-IO. Pre-hospital providers appear to prefer humeral IOs. This type of IO has the faster flow rate, but also is the easiest to displace. (KAF Role III)

218. Although preliminary data from the Baltimore CSTARS (Center for the Sustainment and Readiness of Trauma Skills) study denotes IO flow rate to be greatest with humeral method (humeral tibial sterna), the humeral IO dislodges easier. (JTTS Deployed Director)

219. Essentially all casualties in the last few months were wearing eye protection. We see eye injuries from “inside the wire” activities such as metal grinding. The eye protection currently used is Revision and Wiley X. Both are ANSI Z87-2 approved and authentic Wiley X units have this approval stamped on the frame. The local bazaar sells fake Wiley X, identified by lack of ANSI Z87-2 stamp on the frame. These fake Wiley X eye pro units do not provide adequate protection and this has led to serious eye injuries. Afghan personnel without eye protection who sustain a facial peppering injury pattern from IEDs have nearly 100% open globe injuries. (KAF Role III – Cornea Specialist)

220. KAF Role I Equipment Notes: wanted Hextend but could not get enough prior to deployment, using NS and LR instead; Medics are not allowed to give IV meds, giving IM morphine; want OTFC but has been hard to get; no ketamine; no parenteral antibiotics; no combat pill packs; no TCCC cards; preferred litter is Fox litter; spine boards are carried in vehicles. (KAF Role I – 3rd Infantry Division)

221. A doctor of pharmacy was attached and deployed with 3rd Infantry Division. This increases flexibility for instituting novel pharmaceutical solutions and training. (e.g. nasal ketamine beta project) (KAF Role I – 3rd Infantry Division)

222. In the absence of a “proven” product that can be standardized, the medic will improvise.

This creates variability in care, but also provides innovation. (Tarin Kowt Role I – NSW)

223. BUMED pathway for approval, procurement, and fielding of medical equipment and medications can prove difficult to negotiate. (Tarin Kowt Role I – NSW)

224. Combat First Aiders (CFAs) carry CAT Tourniquet, Quickclot Gauze, NPA, needle for decompression, and Asherman chest seal (ACS). However, they prefer Halo and Hyfin chest seals over ACS. Medics also carry OPA, LMA, and chest tubes. For IV fluids carried – no colloids, only crystalloids (NS, LR). CFAs can also provide IV fluids. For pain management administered – IV morphine and OTFC, no ketamine. A handbook for clinical practice guidelines and protocols is in development. (Tarin Kowt Role I – Australian Forces)

225. Australian Force medics are not issued a medical kit, they buy their own; physicians sign for a “Thomas Pack” at the unit. (Tarin Kowt Role I – Australian Forces)

–  –  –

226. The CRoC may apply pressure too distally for many casualties. There is interest in the abdominal aortic tourniquet. The UK places more emphasis than the US on pre-hospital use of pelvic binders in casualties with suspected pelvic fractures (Bastion Role III – UK)

227. The UK medic aid bag is a “Blackhawk” bag which has been the standard since approximately 2010. Strayer Traction Splints are carried on evacuation platforms. Grab bags for ground medic resupply are also placed on tactical evacuation platforms, and contents are modified based on the MIST report and requests from the POI. Some US evacuation units also use this technique. (Bastion Role I – UK medics; Bastion Role I – USAF Pararescue personnel;

BAF Role I – USAF Pararescue personnel)

228. The UK IFAK is standardized in design (“roll-out” pouch with black cross), content and location of content (2 x pressure dressing, 2 x CAT tourniquet, 2 x Celox Gauze, 2 x Bolin chest seal, 2 x morphine IM syringe, casualty card), and location worn on body (right hip). Additionally, all carry a CAT tourniquet in the left upper shoulder pocket. The UK Surgeon General dictated that morphine IM be carried by all, and each combatant carries two 10-mg morphine autoinjectors. Standardization expedites critical care. (Bastion Role I – UK medics)

229. UK medic equipment notes: They carry the CAT tourniquet and like it; they carry Celox Gauze and like it; unhappy with Asherman chest seal and have replaced with Bolin; carry 3.25ga needles for chest decompression; use sodium lactate to resuscitate casualties in shock and titrate to a normal radial pulse in 250 cc increments; do not currently carry dried plasma;

carry both FAST- 1 and EZ-IO and they like FAST-1 better due to ease of insertion; carry and use both pelvic binders and c-collars; use and like very much the Prometheus litter which is made of thin black material, is very lightweight, and easier to use and drag than other litters; use IM Morphine and OTFC, but no IV morphine (several medics interviewed noted that they believed that IM morphine works better than OTFC); they do not have ketamine, antibiotics, or TXA; they do emphasize filling out a point of injury casualty card, although the medics will often have another team member serve as a scribe for this function. (Bastion Role I – UK medics)

230. UK medics carry morphine and OTFC, no ketamine. Medics can only give morphine IM, not IV. Medics have been giving OTFC since 2010. No pre-hospital antibiotics are provided due to the current rapid evacuation times. (Bastion Role I – UK medics)

231. For the most part, the IFAK is standardized across the USMC but there is some inter-unit variability. Marines carry tourniquets, combat gauze, NPA, chest seals, and needles for decompression. They use SOF-T tourniquets. Two tourniquets are carried by all, one in each shoulder pocket. Not carried on leg, as the leg is affected more by blast MOI. (Bastion Role I – USMC/USN)

232. USMC corpsmen equipment notes: All carry King LTs, 8404s also carry Combitubes; all can do surgical airways; SOIDCs can intubate, but not 8404s; the NARP cric tube is too small, prefer H & H cric kit; capnography should be used to confirm airway placement with intubation and cric; 8404s don’t have capnography, but SOIDCs often do; all have needles for chest decompression; USMC/USC corpsmen have experience with the Bolin, Asherman, and Halo chest seals; Halos stick best - others stick well if the chest is properly prepped; Recon corpsmen prefer the EZ-IO, especially with mini drill; humeral IOs are difficult, they prefer tibial;

8404s like the FAST-1 because it is easy to do; some 8404 corpsmen carry LR or NS as resuscitation fluid; Recon corpsmen have IV morphine and ketamine, but 8404s have neither;

8404s have 2 x IM morphine and 2 x OTFC 800ug; all Marines carry Combat Pill Packs with the correct medications; (OTFC and Pill Packs for USMC/USN was an initiative by CAPT Jeff Unclassified Unclassified Timby, the previous II MEF Forward Surgeon); Recon corpsmen carry parenteral antibiotics – 8404s do not; RECON corpsmen like the CRoC and carry it routinely; the CRoC is carried preassembled; the CRoC MUST be rechecked after application; 8404s do not carry the CRoC;

TXA is carried by RECON and MARSOC corpsmen, but not by 8404s. (Bastion Role I – USMC/USN) Chest Seals (e.g. Asherman, Bolin, Halo, Hyfin, Russell, Sam) are variable in their adhesive abilities. Is the flutter valve beneficial? (Role I – USMC/USN) Is the chest seal itself beneficial?

Or, does it convert a sucking chest wound into a life-threatening tension pneumothorax? “Why do we treat a non-lethal condition (open pneumothorax) with an intervention that may result in a lethal condition (tension pneumothorax)?” (Incoming JTTS Deployed Director) If the size of the chest seal defect is larger than the diameter of the trachea, then air will preferentially move through the chest defect which can be fatal. Many of the chest seals are being placed on small defects which could lead to a tension pneumothorax. (Outgoing JTTS Deployed Director) According to the 2012 study by Eastridge, there were no fatalities during OEF and OIF that were attributed to open pneumothoraces. [Eastridge BJ, Mabry RL, Seguin P, et al. Death on the Battlefield (2001-2011): Implications for the Future of Combat Casualty Care. Journal of Trauma and Acute Care Surgery 2012; 73(6) Suppl 5:431-437.] It is unknown whether modifying the current practice of treating an open pneumothorax with an occlusive chest dressing might cause some of these injuries to then result in fatalities. (CoTCCC Chairman)

233. If the US JFAK is implemented, the bag needs to be functional. (Bastion Role I – USMC/USN) The UK IFAK has a functional bag/container. (Bastion Role I – UK forces)

234. Current Cric Kits are not optimal. Need to optimize and simplify insertion technique, tube lumen size, and tie-down. (Bastion Role I – USMC/USN)

235. USMC/USN medics carry both crystalloid (LR and NS) and colloid (Hextend) IV fluids.

(Bastion Role I – USMC/USN)

236. For pain management, Recon and MARSOC medics carry morphine (IV and IM), OTFC, and ketamine. Corpsmen in other Marine units carry only morphine IM. All desire ketamine autoinjectors. (Bastion Role I – USMC/USN)

237. Ketamine was very useful in a recent casualty who had a GSW to the head and significant trismus. The corpsman was initially unable to insert the King LT. He used ketamine (50 mg) which relaxed the trismus and allowed the King LT to be inserted. (Bastion Role I – USMC/USN)

238. There was unanimous agreement among the USMC/USN physicians and corpsmen interviewed that having a ketamine auto-injector would be a very desirable addition to battlefield analgesia options. (Bastion Role I – USMC/USN physicians and corpsmen)

239. Tranexamic acid (TXA) is carried by Recon and MARSOC medics. It is not being carried by corpsmen in other Marine units. (Bastion Role I – USMC/USN)

240. Cardiologists have used the FemoStop for junctional hemorrhage control following procedures in the hospital. The FemoStop compression device should also be considered for potential pre-hospital application and included during future head-to-head evaluations of junctional tourniquet devices. (Bastion Role I – USMC/USN Cardiologist)

Unclassified Unclassified

241. PJs and aircrews are all on flight status. Mobic was only approved for the USAF flight community 6 months ago. Rated aviation personnel must be ground tested for meloxicam (Mobic) for 7 days. Motrin in contrast does not require ground testing. Thus, if meloxicam is preferred over platelet-inhibiting NSAIDS, then the issue of ground testing for this medication needs to be reviewed. (BAF Role I – USAF)

242. The opioid analgesic option with the best-documented safety record in this conflict is oral transmucosal fentanyl citrate (OTFC). [Wedmore IS, Kotwal RS, McManus JG, Pennardt A, Talbot TS, Fowler M, McGhee L. Safety and Efficacy of Oral Transmucosal Fentanyl Citrate for Prehospital Pain Control on the Battlefield. Journal of Trauma 2012, 73(6) Suppl 5: 490-5.] Some units have not been able to obtain this TCCC-recommended analgesic option. (Salerno Role I – 101st Airborne Division (AASLT))

243. First responders expressed dissatisfaction with the weight and bulk of the Hypothermia Prevention and Management Kit (HPMK). (Role I – 75th Ranger Regiment)

244. Combat wound pill packs (CWPPs) are being used by Special Operations ground units.

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